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Postherpetic Neuralgia

Another common pain syndrome that occurs in older adults is postherpetic neuralgia or shingles pain. This is something that I think is really underappreciated. Essentially, what we’re looking at is that when we’re young, many of us develop chickenpox. As we age, the varicella-zoster virus that causes chickenpox in essence is reborn in certain nerves of the body and when that occurs, it is called herpes zoster. Typically, it occurs in the nerve of the thoracic spine or the ophthalmic branch of the trigeminal nerve. Patients feel a burning, shooting, stabbing pain in that part of the body that can be quite horrific. Antiviral therapies like acyclovir or ganciclovir can reduce the burden of the disease, can reduce pain, and, hopefully, reduce the incidence or the risk of developing persistent shingles pain which is called postherpetic neuralgia.

Now, if postherpetic neuralgia does develop, fortunately, in the United States we have four FDA-approved treatments for it. There are two oral medicines for it and two topical medicines. The two oral medicines are gabapentin and pregabalin. The topical agents are topical lidocaine in the form of a patch and topical capsaicin, which is also administered in the form of a patch. Finally, there is a vaccine for the prevention of postherpetic neuralgia called Zostavax. Zostavax, I think, is very underutilized, unfortunately. It is FDA-approved for use in patients 60 years of age and older, something that’s administered subcutaneously, and should last about five to six years.

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Other One-Minute Clinician

In terms of diagnosis and treatment of neuropathic pain, we have a long way to go. Many patients have a component of neuropathic pain to their overall pain experience that is not recognized by those taking care of them.